Provider Demographics
NPI:1851540272
Name:KEENAN, MARYELLEN
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:KEENAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8201
Mailing Address - Country:US
Mailing Address - Phone:212-604-8177
Mailing Address - Fax:212-604-7568
Practice Address - Street 1:153 W 12TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8201
Practice Address - Country:US
Practice Address - Phone:212-604-8177
Practice Address - Fax:212-604-7568
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329271163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult